There is no perfect method of contraception. Each patient must be approached individually.
However, the options available to women now are vast compared to those two generations ago.
Methods differ in their effectiveness, side effects, participation of the users, expense, availability,
ability to be concealed, and legal/religion/FDA status. Pregnancy rates are 85 to 100 woman-years (85% per
year) without contraception.

The era of modern contraception dates from 1960 when oral contraception was first approved by
the US Food and Drug Administration, and intrauterine devices were re-introduced. A few
catastrophes attributable to oral contraceptive pills (OCP) usage, particularly from the older
higher-dose pills, caused considerable public alarm in the 1970's. Now the birth control pill has
become safer and better tolerated, with reduced dosage of both the estrogen and the progestin
components. The 1990's are seeing multiple reports on the health benefits of the Pill. According
to the 1988 Ortho Survey, approximately 14 million women in the United States use the pill; about
60 million women worldwide use OCPs. ("OCP" usually refers to combined oral contraceptive
pills containing both estrogen and progestin).

Few women are not candidates to take OCPs. Table 1 lists absolute and relative contraindications.
Most of the contraindications are related to the estrogen component. Risks of hormonal
contraception must always be weighed against risks of pregnancy and acceptability of other
options. A woman is 15 to 20 times more likely to die from continuing a pregnancy than from
using oral contraceptive pills.

Studies to look at the complications of oral contraceptive pills are confounded by the higher-dose
pills used in the 1960's and 1970's. Estrogen and progestin doses have been steadily lowered,
with attendant lowered morbidity. The currently prescribed low-dose pills (<50 micrograms of
ethinyl estradiol cause cardiovascular complications; myocardial infarction, cerebrovascular
accident, thromboembolism) almost exclusively in women over age 35 who smoke, or in some
women with underlying medical problems, particularly with conditions predisposing to
thrombosis. Healthy OCP users who undergo surgery are at increased risk of venous thrombosis
and pulmonary embolism. Pills should be discontinued prior to surgery and reinstated six to eight
weeks postoperatively. This, too, should be balanced against the risk of pregnancy.

Breakthrough bleeding is the most common side effect for which women discontinue OCP usage.
This may be due to estrogen or progestin deficiency or to missing pills. Estrogen excess side
effects may include nausea, water retention, vascular headaches, and chloasma. Progestin excess
may lead to increased appetite and weight gain, acne, depression, and pill amenorrhea. With
current low-dose formulations, most women experience mild or no side effects.

Benefits of taking contraceptive pills have been under-publicized. Long-term use is not only safe,
but it is protective against many serious disorders and nuisance complaints. There is no need for
a pill-free interval for reproductive or general health.

The OCP has over 25 preparations, using two different estrogens and several different progestins. The available pills contain fixed and variable-dose ratios. All can claim >99% theoretical effectiveness. Combination pills, using both estrogen and progestin, are taken for 21 days, with a seven-day hiatus between cycles, during which time withdrawal bleeding occurs. The "mini-pill", or progestin-only pill, is taken continuously without a break; bleeding may occur irregularly, not at all, or occasionally as regular menstrual cycles. Additional information can be found under "progestins".

The principle mechanisms of action of OCP's appear to be:

Blockage of ovulation, which is mediated through hypothalamic suppression of FSH, LH and the LH surge.

Creation of "hostile" (viscid) cervical mucus to hamper the transport of sperm and decrease sperm penetration.

Prevention of implantation by altering the endometrium so that it is not receptive to the blastocyst.

Other probable factors of decreased tubal transport and sperm capacitation.

Choosing an oral contraceptive is simpler than it may seem. All pills protect against pregnancy
in most women. Start with a preparation containing 30 or 35 mcg of ethinyl estradiol. The
"newer" progestins, norgestimate and desogestrel, are reported to have equal progestin but less
androgen effect than the traditional progestins (norethindrone, levonorgestrel, etc.). For new
starts, ethinyl estradiol-plus-norgestimate (Ortho-Cyclen, Ortho Tri-Cyclen) may be the best
option, per the theory that less androgen effect will be better for the cardiovascular system. Older
low-dose oral contraceptive pills's which have been well studied and proven safe and effective,
are also recommended (Norinyl 1+35, Ortho-Novum 7-7-7, Demulen 1/35, Ovcon 35, Loestrin
1.5/30, etc.). One study reported that desogestrel-containing oral contraceptive pills's (Ortho-Cept,
Desogen) cause a higher incidence of thrombotic events. These data have not been
corroborated, and these oral contraceptive pills's do not need to be discontinued but are not
recommended for new starts. All tri-phasic pills have the same amount of estrogen throughout
the month, but varying doses of progestin. This is formulated to provide less total monthly
progestin exposure, theoretically enhancing cardiovascular health.

Women discontinue usage for easily definable side effects such as breakthrough bleeding,
amenorrhea or nausea, or for side effects with possible relationships to pill use such as weight
gain, headaches or acne. Other past users have fears regarding cancer, cardiovascular disease,
and future fertility. And many women in the United States are unable to pay for contraceptives,
and instead find themselves dealing with the much more expensive problem of child-rearing.
Better education improves compliance. A patient should know when to contact her physician,
with the potential danger signals listed below. She should also be thoroughly informed about the
safety of the pill and of its benefits.

EARLY PILL DANGER SIGNS

CAUTION

A

Abdominal pain (severe)

C

Chest pain (severe), cough, shortness of breath

H

Headache (severe), dizziness, weakness, or numbness

E

Eye problems (vision loss or blurring), speech problems

S

Severe leg pain (calf or thigh)

See your clinician if you have any of these problems, or if you develop depression, yellow jaundice or a breast lump.

Figure 2

Postcoital contraception, or the "morning-after pill" consists of high doses of estrogen,
progesterone, or both. A common prescription is Ovral two tablets now and two tablets in
12 hours started within 72 hours of intercourse, with failure rates from 0.16% to 1.6%. The
earlier the administration, the greater the efficacy. The physician should first interview the patient
as to timing of probable ovulation and intercourse and any previous unprotected intercourse. He
should perform a pelvic examination and check a beta-hCG prior to administration.

Progestins can be administered on a continuous basis in oral, injectable or subdermal implant
forms. In the United States, the injectable progestin is Depo-Provera, and the subdermal implant
is Norplant. The main drawback to all these methods is unpredictable, irregular bleeding in many
users. The advantage to injectable or implantable forms is lack of user responsibility. (Why do
you suppose most contraceptive methods fail?)

Health concerns revolve around changes in lipid levels. In general, some lowering of HDL (high-density
lipo-protein, the "good" cholesterol) can be measured, but this has not been shown to
contribute clinically to heart disease. Progestins do not promote clotting, therefore, they do not
increase the risks of heart attack or stroke regardless of age or smoking status. Despite this, the
FDA requires the same thrombosis precautions on all hormonal contraceptives because of the
technical approval process.

The oral contraceptive progestins are listed below. In the United States, the injectable progestin
is Depo-Provera, and the subdermal implant is Norplant.

Table 3. Brand Names of Progestin-Only Pills

Progestin

Dose (mg)

Number of Tablets Per Package

Brand Names

Norethindrone (Norethisterone)

350

42/28

Micronor, NOR-QD, Noriday, Norod

Norethindrone (Norethisterone)

75

35

Micro-Novum

Norgestrel

75

28

Ovrette, Neogest

Levonorgestrel

30

35

Microval, Noregeston,
Microlut

Ethynodiol
diacetate

500

28

Femulen

Lynestrenol

500

35

Exluton

Depo-Provera is medroxyprogesterone acetate in a sustained-release suspension, 150 mg IM every
three months. It is extremely effective, with failure rates from 0 to 1.2 per 100 woman-years.
Studied and used extensively throughout the world, Depo-Provera is now approved by the FDA
for contraception and for other indications (e.g., endometriosis, ovulation suppression).

Norplant consists of six subdermal implants (containing 36 mg apiece) of levonorgestrel, which
provide effective contraception for five years, after which the capsules should be removed.
Average annual pregnancy rate is 0.6 per 100. This appears to be the most effective reversible
method of long term contraception now available.

Intrauterine devices are plastic, polyethylene devices impregnated with barium sulfate to make
them radiographic, now containing copper or progesterone, which stay in the uterine cavity. They
cause a sterile spermicidal inflammatory reaction. Very few sperm reach the oviducts, and
fertilization usually does not occur. If it should occur, the inflammatory reaction is also toxic to
the blastocyst, and implantation is prohibited. There are two IUD's currently marketed in the
United States. "ParaGard" (TCu-380A) is a copper-containing IUD with an efficacy lasting eight
years. "Progestasert" is a progestin-releasing IUD which must be replaced yearly.

First-year IUD failure rates range from < 1% to 3.7%. Pregnancy usually follows spontaneous
expulsion of the IUD, occurring most commonly shortly after insertion. Cumulative four to six-
year pregnancy rates are less than 1% per year. An experienced clinician has fewer failures, due
mainly to correct high-fundal insertion.

Pregnancies may occur with the IUD in place. This carries about a 55% risk of spontaneous
abortion. Removal of the IUD after pregnancy is diagnosed, lowers this risk to about 25%.
There may be a higher risk of septic (spontaneous) abortion, but with modern IUD's this is not
certain. IUD's do not increase the risk of ectopic pregnancies, but they are more effective at
preventing intrauterine than preventing ectopic pregnancies. If a woman using an IUD does
become pregnant, she has a higher chance of having an ectopic pregnancy (approximately 3% to 4%).

Concerns regarding the safety of the IUD relate mostly to pelvic inflammatory disease (PID) and
subsequent infertility. Although these concerns are largely unwarranted with modern IUD's, the
American public is still very suspicious of this efficacious contraceptive. The Dalkon Shield was
found to be the main offender and was removed from the market. Other IUD's were removed
from the market because of the cost of defending against multiple malpractice suits. The incidence
of PID in monogamous IUD users is slightly greater than background risk only shortly after
insertion. Exposure to more than one sexual partner greatly increases infectious risks. The ideal
patient for an IUD is a monogamous woman who thinks she may be finished with childbearing.

This is also known as "natural family planning" or periodic abstinence. These include (1) the
rhythm or calendar method, (2) the basal body temperatures (BBT) method, (3) the mucus
method, ovulation or Billings method, and (4) the symptothermal method. They all require couple
education and motivation. It is key to remember here that ovulation occurs 14 days +/- two days
before menstruation. The follicular phase of the menstrual cycle is the one that varies in length,
not the luteal phase. Therefore, a woman can look back and say when she ovulated, but not as
easily ahead to predict the time of the next ovulation.

The rhythm method can only be used effectively in a woman with regular cycles. It is based on
three assumptions: (1) The ovum can be fertilized for about 24 hours after ovulation. (Often
states as up to 72 hours, but this would be a very rare exception.) (2) Spermatozoa retain their
fertilizing ability for only about 48 hours. (3) Ovulation occurs 12 to 16 days prior to the onset
of menses. After charting cycles for several months, a woman can establish her fertile period by
subtracting 18 days from the length of her shortest cycle and 11 days from the longest cycle. The
couple must then abstain from intercourse during this time. Another option for some couples is
to use a barrier method during the fertile period. An example is as follows:

A woman's menses start every 26 to 30 days.
26 - 18 = 8. 30 - 11 = 19.
The fertile interval is from day 8 to day 19 of the cycle.
(Day #1 is always the first day of bleeding.)

Newer developments which have improved the effectiveness and acceptability of fertility
awareness family planning involve using a basal body temperature daily to determine the end of
the fertile period, checking cervical mucus for clear copious, slippery status (Spinnbarkeit) to
establish the onset and end of fertility, and using a combination of all of the above (symptothermal
method).

Failure rates of fertility awareness depend on the motivation and understanding of the participants.
They vary from 11% to 47% and are most commonly a result of conscious deviation from the
rules of the method. Most accidental (method-failure) pregnancies occur as a result of intercourse
prior to ovulation.

Surgical sterilization is increasingly popular as a form of contraception. Approximately one
million sterilizations are performed annually in the United States (recently on more women than
men). The failure rate of a tubal ligation is 3 to 20 per 1000 (younger women fail more often).
Failures fall into one of five categories:

Luteal phase pregnancy (women who are pregnant at the time of sterilization).

Surgical error (30% to 50%).

Equipment failure (mainly laparoscopic methods).

Fistula formation.

Spontaneous reanastomosis (similar to #4).

If a woman who has had a tubal ligation becomes pregnant, it is much more likely than normal
that this will be an ectopic or tubal pregnancy, ranging from 6% to > 50% chance. However,
her overall risk of an ectopic pregnancy is still lower than if she had not had the tubal ligation,
since so few pregnancies occur. Procedure-related deaths are 1.5 per 100,000 compared to a
maternal mortality rate of 10 per 100,000 births.

The most common tubal ligations performed are laparoscopic cautery, Pomeroy method
(especially postpartum), and the spring (Hulka) clip.

Vasectomy is the least expensive, safest, and most efficacious method of sterilization. Pregnancy
rates following vasectomy are 1% to 1.5%. This is the ideal method for stable couples who are
finished with child-rearing. However, since surgical procedures and anesthesia have become safer
for women, they often shoulder the responsibility of limiting fertility.

Coitus interruptus is used as the primary means of contraception by at least 2% of couples in the
United States. In some countries it is the most commonly used approach to birth control.
Anal intercourse is an ancient form of birth control still used in some societies. A physician
should avoid being shocked by alternate sexual practices.

Intrauterine devices are safe and effective contraceptive methods especially for
monogamous females near the end of their reproductive careers.

Barrier methods and rhythm methods are highly dependent on the individuals involved.

Pregnancies in women who have undergone a surgical sterilization should be considered
ectopics until proven otherwise. Likewise, a positive pregnancy in a woman with an IUD
may be an ectopic pregnancy.